Provider Demographics
NPI:1104118108
Name:BETH'EL PERSONAL CARE HOME
Entity type:Organization
Organization Name:BETH'EL PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ABOSEDE
Authorized Official - Middle Name:ADETUTU
Authorized Official - Last Name:OSHINUBI
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:770-736-6439
Mailing Address - Street 1:4327 WEBB MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7579
Mailing Address - Country:US
Mailing Address - Phone:770-736-6439
Mailing Address - Fax:678-609-5540
Practice Address - Street 1:4327 WEBB MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7579
Practice Address - Country:US
Practice Address - Phone:770-736-6439
Practice Address - Fax:678-609-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA756428113A3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances